(a) The survey team composition must be as follows:
  (1) Level I facilities neonatal program staff must conduct a self-survey, documenting the findings on the approved department survey form. The department may periodically require validation of the survey findings by an on-site review conducted by department staff.
  (2) Level II facilities must be surveyed by a multidisciplinary team that includes, at a minimum, one neonatologist and one neonatal nurse who:
    (A) have completed a department survey training course;
    (B) have observed a minimum of one neonatal survey;
    (C) are currently active in the management of neonatal patients and active in the neonatal QAPI Plan and process at a facility providing the same or a higher-level of neonatal care; and
    (D) meet the criteria outlined in the department survey guidelines.
  (3) Level III facilities must be surveyed by a multidisciplinary team that includes, at a minimum, one neonatologist, one neonatal nurse, and a pediatric surgeon when neonatal surgery is performed in the facility, who:
    (A) have completed a survey training course;
    (B) have observed a minimum of one neonatal survey;
    (C) are currently active in the management of neonatal patients and active in the neonatal QAPI Plan and process at a facility providing the same or a higher-level of neonatal care; and
    (D) meet the criteria outlined in the department survey guidelines.
  (4) Level IV facilities must be surveyed by a multidisciplinary team that includes, at a minimum, one neonatologist, one neonatal nurse, and one pediatric surgeon, who:
    (A) have completed a survey training course;
    (B) have observed a minimum of one neonatal survey;
    (C) are currently active in the management of neonatal patients and active in the neonatal QAPI Plan and process at a facility providing the same level of neonatal care; and
    (D) meet the criteria outlined in the department survey guidelines.
(b) All members of the survey team, except department staff, must come from a PCR outside the facility's region or a contiguous region.
(c) Survey team members cannot have a conflict of interest:
  (1) A conflict of interest exists when a surveyor has a direct or indirect financial, personal, or other interest which would limit or could reasonably be perceived as limiting the surveyor's ability to serve in the best interest of the public. The conflict of interest may include a surveyor who, within the past four years, has personally trained a key member of the facility's leadership in residency or fellowship, collaborated with a key member of the facility's leadership professionally, participated in a designation consultation with the facility, or conducted a designation survey for the facility.
  (2) If a designation survey occurs with a surveyor who has a conflict of interest, the department, in its sole discretion, may refuse to accept the neonatal designation site survey summary conducted by a surveyor with a conflict of interest.
(d) The survey team must follow the department survey guidelines to evaluate and validate that the facility demonstrates the designation requirements are met.
(e) The survey team must evaluate appropriate use of telehealth/telemedicine utilization for neonatal care.
(f) All information and materials submitted by a facility to the department and a survey organization under Texas Health and Safety Code, §241.183(d) or this subchapter, are subject to confidentiality as articulated in Texas Health and Safety Code, §241.184, Confidentiality; Privilege, and are not subject to disclosure under Texas Government Code, Chapter 552, or discovery, subpoena, or other means of legal compulsion for release to any person.

Source Note: The provisions of this §133.190 adopted to be effective June 9, 2016, 41 TexReg 4011; amended to be effective June 22, 2023, 48 TexReg 3226